1. Face-to-Face Encounter Final Rule Guidance for Preparation NHPCO November 2010 © NHPCO 2010

2. © National Hospice and Palliative Care Organization, 2010 The CMS final rule Will require a hospice physician or nurse practitioner to have a face-to-face encounter with each hospice patient before their 180-day recertification and for each 60-day recertification period after that date. Will better enable hospices to comply with hospice eligibility criteria, and to identify and discharge patients who do not meet those criteria.

3. © National Hospice and Palliative Care Organization, 2010 What the statute does not permit Does not permit use of a PA or other non-physician practitioner –A change in the statute would be required Does not permit use of telemedicine to perform the visit

4. © National Hospice and Palliative Care Organization, 2010 The process Face-to-face encounter –Attestation for the face-to-face encounter Brief narrative, using face-to-face encounter findings –Attestation for the narrative Recertify patient for next benefit period

5. © National Hospice and Palliative Care Organization, 2010 Recertification Care Map

6. © National Hospice and Palliative Care Organization, 2010 Who can provide the face-to-face encounter? Physicians Employed by the hospice Working under contractual arrangement with a hospice Hospice maintains control Duties – ALL THREE  Conduct face-to-face encounter  Compose narrative  Sign recertification Residents and fellows can serve Attendings cannot do the face-to-face without becoming a “hospice physician”

7. © National Hospice and Palliative Care Organization, 2010 Who can provide the face-to-face encounter? Nurse practitioners Can conduct face-to-face encounter Provide the clinical findings to the physician who is considering recertifying the patient Cannot certify or recertify terminal illness (statutory requirement from 1983) Must be a W-2 employee  Full time  Part time  Per diem

8. © National Hospice and Palliative Care Organization, 2010 When NP does face-to-face encounter… The face to face attestation should include a statement that the clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care.

9. © National Hospice and Palliative Care Organization, 2010 Benefit periods/180 days Based on benefit periods and not on actual days of care. Regulations in 418.22 now require that the benefit period be included on the certification form

10. © National Hospice and Palliative Care Organization, 2010 Timing of face-to-face encounter Face-to-face encounters may be completed no more than 30 calendar days prior to the effective date of the 180-day recertification. Face-to-face encounters may be completed no more than 30 calendar days prior to the start of each subsequent benefit period as part of the recertification process. Gives hospice providers more time to schedule and complete the face-to-face encounter

11. © National Hospice and Palliative Care Organization, 2010 Timing of recertification process Element Face-to-face encounter Accompanying attestation Brief narrative Attestation Recertification complete Time Frame Up to 30 days prior to recertification No more than 15 days prior to recertification

12. © National Hospice and Palliative Care Organization, 2010 Transitions on January 1, 2011 Patients who enter 3 rd benefit period or later before the end of 2010: –No face-to-face encounter required until the recertification period is reached after January 1, 2011 Patients who enter 3 rd benefit period or later after January 1, 2011 –Face-to-face encounter required

13. © National Hospice and Palliative Care Organization, 2010 Where can encounter take place? No requirement that the visit must take place in the patient’s home Could also take place in practitioner’s office Hospice is required to determine whether travel to the practitioner’s office: –optimizes patient comfort –is consistent with the patient’s and family’s needs and goals Ambulance transport not separately reimbursable

14. © National Hospice and Palliative Care Organization, 2010 Checking Hospice History Use Common Working File (CWF) or Health Insurance Portability and Accountability Act (HIPAA) Eligibility Transaction System (HETS) –270/271 transaction MAC can provide an internet portal The HETS system can be a data source for patient benefit periods and eligibility

15. © National Hospice and Palliative Care Organization, 2010 Transfers When a patient in the 3rd or later benefit period transfers to a new hospice –Receiving hospice must recertify the patient –Face-to-face encounter for that current period is not required if new hospice can verify that the previous hospice provided the visit

16. © National Hospice and Palliative Care Organization, 2010 New Patient with Other Hospice Services Face-to-face encounter is required “prior” to the 180-day recertification Verbal certification within 2 days Written certification, including: –Narrative –Attestation Must be completed prior to filing the claim

17. © National Hospice and Palliative Care Organization, 2010 Recertification Care Map- MAP – New Patient With Previous Hospice Care

18. © National Hospice and Palliative Care Organization, 2010 Is the encounter a billable visit? No, the Face-to-Face Encounter considered an administrative function of the hospice physician If a non-administrative service, such as symptom management, is provided – hospice bills that portion of the encounter to Part A –Documentation for visit needed, whether administrative or for services beyond the face-to-face –Documentation – clear and precise

19. © National Hospice and Palliative Care Organization, 2010 More on billing NPs may bill only if they are serving as the patient’s attending Hospices may not bill patients for face-to-face encounters or for any medically necessary physician services provided during the encounter, as these are hospice services

20. © National Hospice and Palliative Care Organization, 2010 Face-to-Face Attestation statement The attestation is a statement from: –Hospice physician or NP Attests that he or she had a face-to-face encounter with the patient The clinical findings of that encounter have been provided to the certifying physician for use in determining continued eligibility for hospice care

21. © National Hospice and Palliative Care Organization, 2010 Attestation statement The attestation should include: –the name of the patient visited –the date of the visit –signature and date by the NP or physician who made the visit Note: The date of encounter does not have to match the date that the attestation was signed; however, both dates should be included.

22. © National Hospice and Palliative Care Organization, 2010 Attestation statement Can use other attestation language, provided that it incorporates required elements Elements of attestation suitable for –NP –Physician Certifying hospice physician MUST be the same physician who made the visit

23. © National Hospice and Palliative Care Organization, 2010 Attestation statement Where should the attestation be located? The attestation and signature can be either: –a separate and distinct area on the recertification form, or –a separate and distinct addendum to the recertification form, that is easily identifiable and clearly titled. The attestation language should be located directly above the physician or NP signature and date line.

24. © National Hospice and Palliative Care Organization, 2010 Electronic signatures Electronic signatures are permitted on hospice certifications and recertifications Narrative and the face-to-face attestation are parts of the certification or recertification -- may also be signed electronically

25. © National Hospice and Palliative Care Organization, 2010 Hospice Risk Management Face-to-face requirement is part of the hospice recertification process CMS can demand and recoup payments if face-to-face encounter is not provided

26. © National Hospice and Palliative Care Organization, 2010 New Tools & Resources from NHPCO  “Clean COPS” – hospice regulations with new provisions included  Face-to-Face Final Rule – PDF Pull Out  Initial Certification Tip Sheet  Recertification Tip Sheet  Initial Certification Sample Forms  Recertification Sample Forms  Admission Care Map – Revised  Recertification Care Map  Initial Certification Audit Tool  Recertification Audit Tool  PowerPoint for Staff In-Service  Frequently Asked Questions

27. © National Hospice and Palliative Care Organization, 2010 Questions?